Author: SSO

Medicare
beneficiaries: listen up! The Administration is introducing a proposed rule
that would arbitrarily base the prices of American medications on prices of
drugs in foreign countries. Proponents of this proposal, known as the
International Pricing Index (IPI), claim that this type of plan would cut
costs, but the truth is, this measure could harm seniors’ access to prescription
medications and stifle medical progress and the development of improved
treatments here at home.

If IPI is enacted, seniors will likely see new restrictions in the number and variety of medication options available to them and their physicians. International reference pricing proposals – which would tie U.S. drug prices to foreign countries that heavily regulate medicine accessibility — could also force a one-size-fits-all approach on beneficiaries, worsening health outcomes by assuming every patient responds the same way to all medications. If seniors are not given a voice or a choice in matters regarding their own healthcare needs, it will be harder to do what their physician believes is most effective.

Seniors must act NOW! Tell the Administration just how harmful enacting IPI and other foreign reference pricing policies could be, both for beneficiaries’ health and for American medical progress. Click here to make your voice heard.

How we pay for our health care is a mystery to most of us. We get our Medicare and insurance bills and they are hard to decipher. We pay money for premiums and when we go to the doctor, the hospital and buy are medicines, but the reason things cost what they do is often a mystery. When we hear the politicians talk about changes to Medicare, they use words and descriptions that are often unfamiliar. What we do know is that when Medicare is changed it often affects us directly, either by access to care or cost. My goal with this blog is to try, and I emphasize TRY, to simplify how the different players in our health care system interact and the forces that influence how they operate. I will also seek to explain the different tools that are used and how each one of them affect your health care access and your cost. My goal is to help you become a more knowledgeable constituent, one that understands your health care today and the ramifications of possible future changes.

I realize this is a long blog, believe me it could have been many times longer. My hope is that this blog gives us a base of understanding, a reference place, that we can use when we get into a detailed discussion concerning possible regulatory and legislative changes.

There are four major players in how we receive our Medicare health care benefits:

All of them have regulations, legislation, costs and competitive forces that affect them.

Patients – • Many of you have seen out-of-pocket costs go up while access to care has become more complicated.

Providers – • Doctors are inundated with regulations that require ever expanding administrative costs and require them to spend more and more time on non-patient contact tasks. Malpractice insurance costs continue to rise which encourages them to protect themselves by ordering more tests, procedures and specialist appointments. • Hospitals have huge fixed costs and are required to treat the uninsured. • Drug manufacturers face the risk and cost of research and development that has raised the cost of developing a new drug to two billion dollars. They are faced with required discounts on drugs while paying ever increasing rebates to insurance companies and PBMs.

Payers – • The government has seen health care prices rise while the population lives longer, drawing on a fund that is dwindling each year. • Insurance companies must keep premiums low to compete, but costs continue to spiral up. • Patients, especially the sicker ones, are saddled with paying a higher percentage of their health care costs.

Middlemen – • Pharmacies are squeezed with paying after the sale rebates and providing a myriad of uncompensated services. • PBMs are faced with a changing business model that may impact their relevance.

This is certainly a complicated business; it is a balance of the free market with a highly regulated environment. It is convoluted and, in many places, inefficient, but it is where we are today.

As the players work to improve our health care, they have tools that they use to offer choices, control costs and direct access. My goal in the explanations below is to define how these tools operate and, more importantly, how their use will impact you, either in access to care or cost.

Deductible – The patient is responsible for 100% of health care costs until this amount is reached. It is used to control unnecessary health care usage. It is a big out-of-pocket expense for patients and should be considered as health care plan choices are made.

Co-pay – An amount the patient pays each time they use a product or service. Payers use this to give the patient some cost to pay to help limit unnecessary usage. It operates a little like a deductible and adds to a patient’s out-of-pocket costs. Co-pays are often higher when seeing a specialist.

Co-insurance – Unlike a co-pay, co-insurance is not a set amount, it is a percentage of the cost of the product or service. This tool can have a big impact on a patient’s costs and its use by insurance companies has increased over the last few years. For instance, there is co-insurance in Medicare’s prescription drug benefit, Part D. If your out-of-pocket costs in 2020 exceed $6,350 dollars you are only responsible for 5% of the cost of the drug. 5% may sound small but with some of the costs of medicines today it could be a large amount. For instance, if you are taking a drug that costs $10,000 a month your out-of-pocket costs for the year would be $8,187. You would reach your $6,350 very quickly and would pay 5% of the drug’s list price after that ($500 a month). That is a lot different than paying a $3.00 co-pay once a month. By the way, the $6,350 maximum out-of-pocket in 2020 increased $1,250 dollars from 2019 rather than the approximately $100 a year increase in the years prior. This happened because of legislation that accompanied Obama care. Many senior advocacy groups fought this unwarranted increase.

Out-of-pocket maximum – Many of you are acquainted with out-of-pocket maximums, it is almost a universal benefit in private insurance. Medicare DOESN’T have an out-of-pocket maximum. Many supplemental and Medicare Advantage plans do, however, offer an out-of-pocket maximum. The Part D drug benefit also doesn’t have an out-of-pocket maximum. This is an area that many people say needs to be changed. We’ll no doubt talk more about this in later blogs.

Prescription Drugs

The following tools are used primarily in the use of prescription drugs that are covered under Medicare Part D and Part B. Part B drugs are usually injected at a doctor’s office or at the hospital.

Step Therapy – This treatment requirement is used by insurance companies to ensure that a doctor has tried the least costly medicine or procedure before prescribing a more expensive solution. This usually applies to medicines and is also called fail first, meaning the medicine must not work on the cheaper option before the more expensive option is tried. This treatment regulation is also used to negotiate with drug manufacturers to lower their price so they can be the medicine first tried in the step therapy requirement. This approach raises a barrier to timely access when the doctor, who knows a patient will not respond to the cheaper medicine must still delay the treatment that works while the patient fails on the first medicine. Another access barrier occurs when a patient changes insurance companies and must repeat the step therapy/fail first protocol before they get access to the medicine that had preciously proven to work for them. It is also important to mention that doctors sometimes receive payments for using specific, often expensive, medicines. This is one tool the insurance companies use to control costs.

Drug tiers – This tool puts different medicines in different tiers or categories, historically 3 or 4 but the number of tiers seems to be increasing. These tiers usually go from least expensive to more expensive, with increasing amounts of patient co-pay or co-insurance as the tier gets higher. It is a way to encourage a patient to use the least costly medicine. It also is used to negotiate with drug manufacturers to lower the cost to the insurance company for inclusion on a lower, i.e. higher usage, tier. Identifying which tier your medicine is in can make a huge difference in your out-of-pocket costs.

Importation – There is a disconnect between the price of drugs in America and the price of drugs in some other countries. This is one of the most complicated areas of health care. Some have proposed importing drugs from Canada. Some states have even passed legislation to allow the importation of medicines. There are safety issues and supply issues involved with this approach. Canada itself has said it couldn’t authorize, support or guarantee the safety of drug importation into the U.S. This is a tough issue that will take some big changes to rectify. This is another area we will pursue in later blogs.

International Reference Pricing – This government authored approach seeks to solve the problem described in importation of other countries paying less for medicines. It uses drug prices from some selected countries to set the maximum price for those drugs in America. This solution, which seems simple, is fraught with many questions and problems. We will delve into those questions and problems in a later blog.

Non-interference/government negotiations – This part of the initial Part D legislation left the negotiations of drug prices to the forces of the free market. While it seems like allowing the government to use its force of the millions of Medicare beneficiaries to negotiate lower prices would be beneficial, it isn’t supported by studies and projections. The main barrier is the need to restrict the formulary (the list of drugs available under Part D) to generate any leverage on drug prices. It would be a recipe for access restrictions for life saving medicines. This is another area for future discussion on this blog.

These are just a few of the tools and just scratches the surface of the complexities of our health care system. Hopefully it will give us a base for better understanding any proposed changes in the regulations and legislation that govern Medicare.

Happy
Holidays! I hope everyone’s preparations for family and friends this holiday
season is going well. There’s a lot of things going on this time of year to
keep us all busy. As I mentioned in my last blog, one of the most
important year end tasks is reviewing your Medicare insurance coverage,
including your Part D prescription drug plan. Because I moved to a
different state it was especially important that I reviewed my coverage and in
doing so I had some interesting experiences and some money saving
discoveries. I think by going through some of the decisions and tradeoffs
I had to make, they might help us all better understand the policies and
regulations that are in place now or how the changes that are being considered
by our leaders in Washington might affect each one of us.

As I
mentioned I moved to a different state and that move gave me some broader
choices. Previously, I had a supplemental insurance plan and a
stand-alone Part D plan. The availability of Medicare Advantage plans in
my old state were limited so a supplemental plan was the best choice for my
wife and myself. In my new state I had the choice of various Medicare
supplemental plans, but I also had the choice of five different Medicare
Advantage plans. Since the premiums are often less or zero with Medicare
Advantage, I was very interested in what these five plans had to offer.
Here are just a few things that I had to consider when looking at the Medicare
Advantage plans offered in my state:

Were my new doctors in the PPOs?

What doctors were part of the HMOs?

What would my new premiums be?

What were the copays for an office visit to my primary care doctor?

What were the copays for an office visit to specialists?

What was the copay for a visit to the emergency room?

Did the plan include Part D, if so, did it cover the prescription drugs that we currently use?

What were the copays on the medication?

Was any medication on specialty tiers?

Was coinsurance part of the plan, if so, what was the percentage?

What was the yearly out-of-pocket maximum for health services?

Did the plan include dental, hearing, eyesight or other benefits (like silver sneakers)?

There was a
lot to consider and a lot of acronyms and terms that I had to understand.
It was no small task and took considerable time. It was a little easier
given I’ve been involved in health care policy for over 20 years, but it was
still time consuming and arduous at times. After I had made my
preliminary decision, I used another resource that was available to me as a
military veteran. When I first joined the Air Force, I had the
opportunity to use USAA for my car insurance. I’ve gone on to use them
for other insurance and financial needs and they offer a phone number and
assistance for choosing insurance plans. I’m not selling USAA products, I
don’t sell anything on this blog, but I want to remind you that you should
research all the resources available to you and take advantage of any help
available. I did and was very pleased with the help and advice I got from
the USAA person.

In the end I
chose a Medicare Advantage PPO plan and found that I saved a large amount of
money on premiums. I had to balance that with an increase in my yearly
out-of-pocket maximum and some higher copays. I’ll have to see what kind
of care I receive, but on balance I think I will be better off.

I hope you
are satisfied with your insurance or made a change during this open enrollment
period that will give you better benefits or cost less. As I’ve said
before this blog will focus on you, the consumer and the impact that
regulations and legislation will have on your access and cost. Health
care is complicated, you probably had that driven home as you reviewed your
coverage. I will work to try to simplify the Washington rhetoric and boil
things down to show how their proposals and solutions will affect you.
As part of this
endeavor my next blog will define some of the terms that are used in health
care insurance, regulations and legislation. My definitions will focus on
how these different items affect you and your level of care or
pocketbook. Ever wonder what the difference is between copay and
coinsurance? Watch for my next blog, that will strive to demystify this
complicated thing we call health care.

I know that you have been getting bombarded with emails,
television ads, and mail telling you to change your enrollment to a new money
saving Medicare plan. While I’m not here to sell you insurance I am here to encourage
you to review your Medicare or Medicare Advantage plans and your Medicare Part
D plans. It quite possibly could save you money and give you easier access to
critical medicines and procedures.

This is the time where you can review and make changes to existing
plans. Medicare and Part DOpen Enrollment started on
October 15th and lasts until December 7th. There is also a
separate Medicare Advantage Open Enrollment Period which lasts from
January 1st through March 31st every year.
You can alter Medicare Advantage plans during both periods.

As a quick refresher – Medicare Advantage plans are offered
by a private company that contracts with Medicare to provide all your Part A
and Part B benefits. Medicare Part D plans provide coverage for prescription drugs
but unlike Parts A and B you are not automatically enrolled and must opt into a
Part D plan.

For those turning 65, now is a great time to take a close look at
your options and select a Medicare plan that matches your needs based on the
medications you take and the coverage offered. If you’re already a Medicare
beneficiary and have a Medicare Advantage or Part D plan, this time of year is
still important to take a look at how your care needs have changed and make
sure your plans still work best for you.

It’s especially important to review your plans if you have had
some changes, like some new health issues, retirement, added some prescription
medicines or were able to go off some medicines you had been taking. Another
change that could impact the type and cost of your insurance is if you moved.

I just moved to a different state and I’ve started the process of
reviewing all aspects of my health insurance to make sure myself and my wife
have the right coverage at the right price.

There are a number of tools and resources available. We have some of those resources under are Medicare tab at the top of the page. We also have information on our sister website Medicare Today to help you find information on Medicare, your eligibility and how to enroll. There is also a very helpful and newly upgraded plan finder tool that can help you find plans based on where you live. To access this easy-to-use plan finder click here. You can also use this graphic that contains helpful tips for reviewing plans during the open enrollment period.

For seniors, taking these little steps to review and renew plans
will make all the difference to your health. We all know time flies when you
are having fun, so take a quick look at your coverage during the next few days
and ensure your plans are fitting your future health needs.

I’m a former CEOof two Senior Advocacy groups and have been involved in public policy for older Americans for over twenty years. I’m looking forward to talking with you about the issues that you face as you try to navigate the always complicated and often changing Medicare program.

As we honor veterans this week, I will join everyone in thanking those who served in our countries armed forces. As a former B-52 bombardier, who lost a crewmember and friend last week, I understand the challenges our veterans face.

My approach to communicating with you is to simplify the policy issues that affect your healthcare, ask those in the know common sense questions about the issue and then translating all the information into language we all can understand. The common denominator in all my communication will be to relay the affect every policy will have on YOU, the most important part of Medicare. I’ll focus on how a certain policy will affect the amount of money you will spend or how your access to a certain medicine or procedure will be affected. My goal will not be to judge any specific entity in the supply line of players who supply our healthcare. I will endeavor to focus solely on the impact that a specific policy will have on you, the patient . . . the consumer.

It will then be your turn to speak out, to tell everyone how you will be impacted, how you see a specific solution working, to present your ideas on a solution that you think will work better. Our law makers in Washington often lose touch with the realities that older Americans face each day. This will be your chance to speak out, to tell those in Washington how you feel. We will always be open to your comments, which you can leave by clicking here or on this button anywhere you see it on our web page.

Check the web page periodically to see what new issue has sprung or to see some helpful advice we might have as you navigate through the Medicare labyrinth.

Can you believe how fast summer has flown by? Although the summer festivities may be starting to wind down, the exciting news is that fall is right around the corner—along with cool weather, changing leaves, and the beginning of the holiday season!

This time of year is when children go back to school and people wind down their vacations. This means that many people will be in close proximity, which unfortunately increases the chances of being exposed to individuals who may be harboring contagious illnesses. The good news, however, is that there is an easy way for us to protect ourselves as seniors—making sure our vaccinations are up to date!

August is National Immunization Awareness Month, and a great time to revisit our overall health and ensure that we are utilizing the most effective tools possible to protect ourselves from potentially deadly diseases. Often, seniors may incorrectly assume that vaccination is only important for children and young adults, but this could not be further from the truth. In fact, some diseases, like Pneumococcal disease, are common and fairly benign in kids but present much more danger to older adults.

The CDC even recommends specific vaccinations for seniors, including pertussis, tetanus, shingles, and the seasonal flu shot. There is a special tool, which you can find here, that allows you to take a quiz and see which vaccinations are recommended for you. It is also critical to speak with your doctor about your vaccination history to make sure you are being properly protected. Most necessary vaccines are covered under Medicare Part B and Part D, enabling us all to have access to these potentially life-saving treatments.

As seniors, one of the easiest ways for us to protect the health of our friends, families, and ourselves is through vaccination. Not only will making sure our vaccines are up to date help give us peace of mind as we enter the new season, but could also potentially save our lives. Getting your vaccines is a critical component of maintaining our health and wellbeing, so make sure you are educating yourself and taking the proper steps this August!

It’s that time of year—the results of the Senior Satisfaction Survey from our partners over at Medicare Today are in! Since 2007, researchers have surveyed seniors to measure our level of satisfaction with our Medicare Part D plans in order to take a critical look at the program and ensure that our needs are being addressed.

The purpose of the Senior Satisfaction Survey is to gauge the success of Medicare Part D, examine what aspects of the program are working, and take a look at what the program can be doing differently to achieve maximum success for American seniors. Each year, the survey has demonstrated that seniors are pleased with their Medicare Part D plans, including their coverage options and the prices they pay for their medications.

This year, nearly nine in 10 seniors report being satisfied with their Medicare Part D coverage. Some other key findings include:

93 percent of seniors say their prescription drug plans are convenient to use

86 percent of seniors report that their Part D plans work well

85 percent of seniors view their prescription drug plans as a good value that provide coverage at a fair price

81 percent of seniors are happy with their ability to compare prescription drugs covered under Part D and choose what best works for them

88 percent of seniors say that their Medicare Part D plans are delivering on their promises

These results are exceptional and demonstrate just how happy seniors are with the current state of their Medicare Part D coverage. Although some changes are being proposed to the program by the Administration and Congressional leadership, it is critical that seniors continue to advocate for ourselves by urging lawmakers to protect the integrity of Medicare Part D. We must also continue to push policymakers to support improvements that will strengthen affordable access to medications.

There is a rumored proposal in the works that could harm Medicare Part D and the seniors that rely on this critical program. This proposal would harm Medicare by applying a government-imposed inflation rebate on Part D medications that could negatively affect the program’s successful market-based structure.

By unnecessarily inserting government-imposed inflation rebates, this policy would violate the spirit of the non-interference clause, which has allowed competition between Part D plans to hold down costs and has been key to Part D’s success since its inception. This penalty could also raise premiums for beneficiaries, as this type of change has the potential to eliminate the privately negotiated price protection rebates that are currently used to subsidize premiums.

Not only would this type of proposal undermine the success of the Part D program, but it could also reduce the incentive for future innovation in health care. Inflicting such a policy on Part D medications could have the harmful consequence of discouraging future investment in medical research, harming beneficiaries, especially those with chronic or complex conditions who rely on the program to access new break-through cures.

There are numerous proposals that, if enacted, would serve to meet the needs of seniors. This is not one of them. It is critical that you act NOW to tell your Member of Congress that these cuts to Medicare through government-imposed inflation rebates are the wrong way to lower Part D costs. Join us TODAY in making our voices heard by clicking here!

Each June, seniors and advocates celebrate Alzheimer’s & Brain Awareness Month all over the country. As the month concludes, we thought it would be helpful to discuss the importance of preserving brain health a “check up from the neck up”—a critical aspect of maintaining a healthy lifestyle as we get older. The brain is such an important and complex organ, and injuries and diseases affecting its performance can affect the way we think, act, feel, and behave.

Alzheimer’s disease is a type of dementia that causes problems with memory, thinking, and behavior. Dementia is a general term for memory loss and other issues with cognitive ability that are impactful enough to seriously disrupt a person’s day-to-day life. Alzheimer’s disease accounts for the majority of dementia cases in the United States—estimated to be between 60 and 80 percent.

More than 5.8 million Americans are living with Alzheimer’s disease, and this number is projected to grow to 14 million individuals by 2050. According to the Alzheimer’s Association, early diagnosis initiatives can help with managing symptoms, however, only 16 percent of American seniors say that they receive regular cognitive assessments from their healthcare providers. You can watch a quick video here with some important statistics about the disease and ways to get involved with finding a cure.

Similarly, brain injury is thought to increase the likelihood of developing Alzheimer’s, other types of dementia, and overall cognitive decline. Fortunately, Medicare programs cover many testing and treatment options for older Americans who suffer from brain injury, and although Alzheimer’s disease specifically doesn’t currently have a cure, there are a number of treatment options available that can help manage symptoms.

As always, it is critical that we as seniors make sure we know exactly what our specific Medicare plan covers, including inpatient treatments and prescription medications that can help treat brain injuries and related illnesses. You can learn more about coverage options here to ensure that you are informed about how to take care of your brains!

Calling all seniors! Did you know that Congress is considering a health care policy that would utilize binding arbitration to set prescription drug prices? This practice, which some policymakers incorrectly assume will be more effective than free market negotiations, could authorize third party arbitrators to set legally binding prices using standards set by the government.

This harmful proposal could affect Medicare Part D beneficiaries by fundamentally altering the competitive structure of the Part D program that allows for increased choice and lower costs for seniors. In fact, binding arbitration could even reduce incentives for cost-saving features like rebates, which helped seniors save up to 70 percent on some medicines.

Binding arbitration is a dangerous proposal that would likely undervalue individualized care for seniors. Inserting government bureaucrats in the middle of the doctor-patient relationship not only allows biased, controversial third parties to dictate the price of care for vulnerable patients but it could also disrupt already effective treatment plans. Further, these government middlemen could also reduce incentives needed for progress in drug innovation and stifle progress in the pharmaceutical space.

It is critical that we call on Members of Congress to abandon this harmful proposal for the sake of seniors nationwide. Threatening access for life-saving medications, disruptions in the doctor-patient relationship, and a decreased focus on medical innovation is simply wrong.

Join us TODAY in telling your Member of Congress to reject this dangerous proposal for the health and wellbeing of seniors and people with disabilities nationwide. You can help send this message by signing on to this letter here!